On May 21, 2020, the San Carlos Apache community in Arizona saw its first patient who tested positive for COVID-19. The tribe was one of the hardest hit in the country with an overall incidence of COVID-19 infections at 30% and the death rate at 1.4% at its peak. Here is the story of the San Carlos Apache Healthcare Corporation’s response to the pandemic and mitigation strategies centered around community engagement and close cooperation with strategic partners at all levels: local (tribe), state and federal.
First, a quick primer about the community. The reservation spans 1.8 million acres with a population of about 16,000. It is located approximately 90 miles east of downtown Phoenix and extends north to the Salt River, where it borders the Fort Apache Reservation. While much of the lands are rugged and inaccessible terrain, the towns of San Carlos, Peridot and Bylas are where most tribal members live.
SCAHC is a Tribal Contract or Compact Health Center (also called a 638 facility) operated by the tribe, which administers the operations and funding (with some federal financial support) of the hospital and related services. They are a consequence of tribal sovereignty, which encompasses the provision of healthcare and welfare to tribal members, who are exclusively accepted as patients.
On March 11, 2020, SCAHC officially went under “Incident Command” as soon as the valley’s positives indicated an imminent risk of spread to the community. The executive team worked to define their approach and response to COVID-19 to mitigate spread and minimize health impacts on the tribal community. The response was defined by the long-standing disparities in both health and access to health services for Native Americans. The team identified a need for enhanced collaborative efforts from all tribal partners, including the community at large. Native American communities practice the traditional lifestyle that includes multigenerational households and close interaction within large family groups. The community’s behavior would directly impact the ability to continue hospital operations and care for patients: more than 70% of the hospital staff are tribal members, and community spread was likely to have a detrimental effect on hospital operations.
SCAHC worked with the Tribal Emergency Response Commission and the Tribal Department of Health and Human Services to launch educational campaigns on a variety of platforms to reach all levels of the community. These included the distribution of CDC educational materials translated into the Apache language by tribal elders; an enhanced use of visuals in both these materials and in signs posted throughout the community; the use of the radio in the Apache language to reach the older generation; and the use of social media platforms. To ensure every tribal member was reached and provided with comprehensive but accessible information about symptoms, risks and preventive measures, SCAHC implemented a resource-intensive, week-long effort of door-to-door education. The teams were composed of hospital and DHHS staff accompanied by community members. They also distributed hand sanitizers, thermometers and contact information.
SCAHC also served as an advisory member of TERC, which provided recommendations to the Tribal Council about communitywide safety and mitigation measures. To prevent infections by outsiders, the tribe limited access to nontribal/noncommunity members to the reservation by establishing roadblocks on secondary roads and instituted reservation-wide lockdowns to minimize social gatherings and the potential spread of the virus within the community. The hospital launched a targeted testing protocol and set up testing sites outside of the hospital.
A significant and impactful strategy deployed by the tribe in partnership with SCAHC and DHHS was to establish an alternate care site to contain any potential disease spread. The tribe designated one of the closed casino hotels as the ACS. By tribal resolution, all patients tested positive who resided within the boundaries of the San Carlos Apache reservation were transferred to the ACS to quarantine or isolate. At the ACS, basic medical services, including 24-hour nursing care, were available in the event of progression of symptoms and triaged urgent needs. An on-call provider was also available at night for urgent needs.
SCAHC began administering vaccines on Dec. 17 in a phased approach to the community, and quickly worked through those phases to provide vaccines through a walk-in vaccine clinic. When we progressed 50% through a phase, we opened the vaccinations to the next group and were aggressive with vaccination efforts. We also used mass vaccine drive-thrus, community pop-up clinics and door-to-door strategies to reach the community with vaccines. This was done to remove barriers of access to all who wanted to be vaccinated to protect their families and communities.
Additionally, SCAHC dedicated a team to call elders and high-risk patients to educate them and offer the vaccine. SCAHC used a variety of strategies to reach those who did not have phones or transportation to the hospital. These include walk-in clinics, mass drive-through vaccination events, community pop-up clinics and door-to-door efforts. To date, more than 77% of tribal members have received their first dose and 56% have completed their vaccine series.
Contingency and advanced planning allowed for accumulating appropriate levels of PPE. Building the skill capacity of staff permitted them to be deployed to various areas of clinical needs and patient surges, and aggressive vaccinations led the way to a faster recovery. The vaccination program resulted in San Carlos getting ahead of Arizona’s vaccination efforts and percentages, leading to significantly fewer infections, hospitalizations and deaths. Partnerships were leveraged to synergize efforts toward a unity of voice and purpose—we are stronger together.
Nam Le-Morawa, DPT, is COO for Professional Services, San Carlos Apache Healthcare Corporation.